Socket Preservation Using Dentin Mixed With Xenograft Materials - A Pilot Study - PMC

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Materials (Basel). 2023 Jul; 16(14): 4945. PMCID: PMC10382043

Published online 2023 Jul 11. doi: 10.3390/ma16144945 PMID: 37512221
Socket Preservation Using Dentin Mixed with Xenograft Materials: A Pilot Study
Elio Minetti, Conceptualization, Investigation, Data curation, Writing – original draft,1,† Andrea Palermo,
Conceptualization, Validation, Writing – original draft,2,† Paolo Savadori, Conceptualization, Software, Resources,1,3
Assunta Patano, Formal analysis,4 Alessio Danilo Inchingolo, Methodology, Resources,4 Biagio Rapone, Software,
Investigation,4 Giuseppina Malcangi, Formal analysis, Writing – review & editing,4 Francesco Inchingolo,
Methodology, Supervision, Project administration,4,* Gianna Dipalma, Validation, Supervision, Project
administration,4,* Francesco Carlo Tartaglia, Investigation,5 and Angelo Michele Inchingolo, Methodology,
Visualization, Project administration4
Nikolaos Silikas, Academic Editor
Abstract
Background: The use of human dentin matrix could serve as an alternative to autologous, allo‐
genic, and xenogeneic bone grafts due to its osteoinductive characteristics. The limitations of its
use is tooth availability and that it is often necessary to mix it with a biomaterial. Aim: The aim
of this study was to analyze a mix of two different graft materials with different reabsorption
ranges when the dentin graft material was not sufficient for full socket preservation. Methods:
Seven socket preservation surgeries were carried out employing a mixed graft material con‐
taining 50% dentin and 50% xenograft. After four months of recovery, the implants were posi‐
tioned. At the time of the prosthesis placement and implant surgery, bone samples were col‐
lected. Results: The histologic analysis revealed no inflammatory or infective reaction against
the seven biopsies. The histomorphometric graft analysis revealed an amount of New Bone of
29.03 ± 6.57% after 4 months and 34.11 ± 5.02% after 8 months. Conclusions: The two graft
materials had a different volume reabsorption rate: 71% after 4 months and 90% after 8
months for dentin, and 6% after 4 months and 26% after 8 months for the xenograft. The
space created by the dentin reabsorption increased the quantity of new bone.
Keywords: socket preservation, dentin matrix, xenograft material, autologous tooth graft,
biomaterials, oral surgery
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10382043/ 1/21
1. Introduction
The possibility of positioning dental implants in sites that have undergone tooth extraction is
strictly reliant on the available bone volume that results from the bone healing and remodeling
after tooth removal. Bone remodeling is a continuous, complex process that involves all the
bone tissues in one organism and can lead to the resorption of alveolar bone when a tooth is
no longer present [1]. This process results in a vertical volumetric alveolar bone reduction
(1.67 and 2.03 mm) and a horizontal volumetric alveolar bone reduction (3.87 mm) [2].
These variations in soft and hard tissues mainly occur during the first year after extraction [3].
To minimize these problems, a socket preservation technique has been suggested as it helps re‐
duce soft and hard tissue volumetric contractions (0.36 mm horizontal bone loss and 0.58 mm
vertical bone loss) [4].
After tooth extraction, the socket undergoes a series of complex healing processes—starting
with clot stabilization, fibrin production, and recruitment of osteoblasts, which are responsible
for new bone growth. Various biomaterials and procedures with different functionalities—such
as osteoconduction and osteoinduction—have been documented to maintain alveolar volume,
depending on the characteristics of each material [5].
Several studies have provided histological evidence of new bone formation in extraction sock‐
ets following the application of barrier membranes in combination with allogeneic [6] and
xenogenic [7] bone grafts.
Guided bone regeneration (GBR) was introduced as a treatment approach with the objective of
promoting bone regeneration through the utilization of barrier membranes.
The therapeutic protocol of GBR involves surgically placing a membrane that prevents cell mi‐
gration, thereby sealing off the area of the bone requiring regeneration.
By creating and sustaining an isolated space, the membrane establishes an environment con‐
ducive to the presence and activity of osteoprogenitor cells [8,9].
The graft materials are classified as autograft (bone from the same patient), allograft (bone
from another human), dentin (material from the patient’s own teeth), xenograft (bone from an‐
other species), and alloplast (synthetic material). Approximately 87% of the graft material mar‐
ket consists of alloplast and xenografts (infodent 12-2018), and their only property is osteo‐
conduction. Most sintered HAP ceramics, including the porous ones, have large crystals that are
difficult to remodel. Therefore, residues of graft material can impede the space required for
new bone formation, as they are reabsorbed with great difficulty. Placement of the biomaterial
in the fresh extraction socket can slow healing. Bio-Oss® particles, for example, are not re‐
sorbed, but become surrounded by new bone [10,11,12].
In 2003, Norton found about 26.9% of new bone and 25.6% of xenograft material following re‐
modeling (Bio-Oss) [13].
Autogenous bone has been extensively used due to its osseoinductive, osseoconductive, and
osteogenic properties [14,15]. However, the high resorption rate, donor site morbidity, and lim‐
ited availability can compromise the clinical outcomes of autogenous bone grafts [16,17].
Xenografts are the most commonly used osteoconductive graft material, and Corbella et al.
evaluated 273 biopsies from 14 studies [18,19,20].
The use of dentin matrix from autologous extracted teeth could be an alternative, promoting
bone healing in intraoral defects [21,22,23,24,25,26,27].
Urist et al. discovered the osteoinduction potential of demineralized dentin matrix over 50
years ago, when they invented the tooth-grafting process [28,29]. More recently, Bessho et al.
demonstrated the existence of bone morphogenetic proteins (BMPs) in the matrix of human
dentin. In particular, ectopic bone formation and the presence of osteoblasts were observed in
rat muscle after demineralized human dentin matrix grafting [30].
Dentin should be considered a graft material with osteoinductive and osteoconductive proper‐
ties due to the presence of numerous proteins shared with bone within it [31,32,33]. Recent
human studies have shown the effectiveness and safety of chairside-prepared autogenous par‐
tially demineralized dentin matrix for clinical applications in bone regeneration procedures re‐
lated to implant dentistry, including alveolar ridge augmentation, socket preservation, and max‐
illary sinus floor augmentation [33,34,35,36,37,38,39].
Several experimental findings from a thorough literature analysis show how demineralized
dentin matrix affects osteodifferentiation in vitro and increases osteoinduction in vivo. Some
authors theorize that the demineralization process allows for better bone augmentation com‐
pared to non-demineralized dentin—likely because the availability of these molecules increases
with matrix demineralization [32,40,41].
The chemical composition of bone and dentin is quite similar, consisting of an inorganic por‐
tion made of hydroxyapatite and an organic portion mainly composed of collagen type 1 and
other secondary proteins [42,43,44].
The proteins in the extracellular matrix (ECM) of bone and tooth are better protected. The ap‐
atite in which the proteins are embedded apparently provides significant protection against
postmortem destruction caused by chemical and physical agents. As a result, these structures
can be preserved for many thousands of years after death [45]. Demineralized dentin’s capa‐
bility to promote bone regeneration is highly comparable to the promotion of new bone
growth by bone autografts. These mechanisms are characterized by cellular differentiation
processes triggered by the interaction of cells that stimulate bone growth and cells that re‐
spond to it [31,32,33].
An innovative medical device capable of processing extracted teeth and producing a suitable
graft material has been introduced to the market. This system guarantees fully automated dem‐
ineralization, grinding, and cleaning procedures, eliminating the need for human intervention
in the process. According to some researchers, the mineralized allograft is only claimed to be
osteoconductive; however, when the material is resorbed and remodeled throughout the bone
regeneration process, osteoinductive elements within the mineralized structure may also be‐
come accessible [46,47,48].
However, it can be challenging to fill large bone defects using only demineralized dentin, due to
its limited availability. Therefore, in a study conducted by Umebayashy et al., they suggested
combining different materials when dentin alone is insufficient. Specifically, they described a
case where bilateral alveolar bone and sinus floor augmentation were achieved by grafting a
mixture of demineralized dentin, cancellous bone particles, and medullary bone particles, fol‐
lowed by full-arch implant rehabilitation. No complications occurred after 4 years, and both the
bone volume and physiological bone volume were successfully maintained [49].
Another study examined the use of bone marrow stromal cells engineered to express the
dentin matrix protein-1 gene, in combination with Bio-Oss(®), for sinus augmentation with si‐
multaneous implant placement in dogs. Bone regeneration and osseointegration were evalu‐
ated using histologic and histomorphometric methods after a three-month healing period. The
combination of materials demonstrated osteoinductive and osteoconductive bone regeneration
capacities [50].
The primary goal of the study was to investigate situations where there was limited tooth struc‐
ture available for regeneration, requiring the utilization of grafting materials, and to evaluate
the effectiveness of this approach and determine if it demonstrated any favorable attributes.
Based on the Norton considerations [13], this study aimed to observe and compare the graft
reabsorption curve, measured through histomorphometry after 4 months and 8 months. The
goal was to determine if it is possible to mix two different graft materials with varying reab‐
sorption ranges when the dentin graft material alone is insufficient to fill the entire socket
preservation. The study aimed to take advantage of dentin reabsorption in such cases.
2. Materials and Methods
2.1. Study Design and Patient Selection
Seven subjects (3 men and 4 women) with a mean age at surgery of 53 ± 67.89 years (ranging
from 42 to 63 years) were enrolled and treated following the described protocol. All patients
considered for inclusion in the study were in good health and treated in three dental clinics lo‐
cated in Italy.
The sample size of this study consisted of 7 cases after 4 months and the same 7 cases after 8
months. Experienced operators performed the surgical procedures and all patients provided
written informed consent prior to participating in the study. One autologous tooth (extracted
due to cavity or periodontal disease), either element 4.6 or 3.6, was extracted from each pa‐
tient and used to prepare a tooth graft. The tooth graft was mixed with 50% xenograft material
and utilized using socket preservation techniques. All socket preservations involved three-wall
defects. The graft was covered with an absorbable membrane (Osseoguard, Zimmer, Collagen
matrix, Inc., Okland, NJ, USA).
The marginal gingival tissue was slightly, gently stretched to cover the alveolus and closed by
single sutures. The socket was completely filled with the graft.
The primary objective of this prospective study was to analyze the histological differences and
evolutions between the two graft materials used for socket preservation. To achieve this goal,
two histological samples were taken: the first after 4 months of regeneration and the second
after 8 months of regeneration.
Following the operation of the TT Tooth Transformer device, a combination of 50% autologous
tooth and 50% xenograft (Bio-Oss, Geistlich Pharma AG, Wolhusen, Switzerland) was used to
preserve the sockets of 7 patients after tooth extraction.
To understand the volume occupied by each individual graft material, a test was conducted. The
test involved loading a defined value of granules (1 cc) into a syringe. Drop by drop, demineral‐
ized water was introduced until the volume of the granules was reached. The quantity of water
used represented the measure of the volume occupied by the space between the granules. This
method allowed us to understand the percentage change in the material over time through his‐
tomorphometric values (Figure 1).
Figure 1
The syringe containing 1 cc of granules and demineralized water inserted drop by drop.
2.2. Inclusion Criteria
The general inclusion criteria were those commonly adopted in the three clinics: patients aged
at least 18 years, in good general health (ASA-1 and ASA-2), and able to undergo surgical and
restorative procedures. Specific criteria included patients needing socket preservation after
tooth extraction to maintain the required bone volume for implant insertion. The reasons for
extraction had to be periodontal disease, fractures, or caries. The study group comprised seven
patients with seven sites requiring three-wall socket preservation.
2.3. Exclusion Criteria
Patients with a history of tobacco use within the last 6 months, allergies, diabetes, healing dis‐
orders, HIV, cancer, metabolic diseases, bone diseases, systemic corticosteroid use, intravenous
or intramuscular bisphosphonate use, immunosuppressive agent use, radiation therapy, or
chemotherapy (within the last 2 months) were excluded. Pregnant women were also excluded.
These exclusion criteria were chosen to select cases that may not be influenced by any underly‐
ing pathologies.
2.4. Surgical Procedures and Follow-Up
Histological and morphometrical data were detected in accordance with the protocol recorded
at the University of Chieti (Ethical Committee approval: request ID richhtnc4, protocol N_1869
12 December 2018, approved 17 verb 21.03.19 St.638 PI Perfetti). Extractions were performed
after administering antibiotics. Bone defects were filled using the following technique: The
tooth was first thoroughly cleansed of any remaining calculus, then the root surface was pol‐
ished with a diamond drill and ample irrigation. Previous fillings, such as composite or gutta-
percha, were removed. The tooth was divided into small pieces and placed inside the grinder
(Tooth Transformer TT, Milan, Italy). The single-use device was opened, and a small package of
disposable liquids was placed in the designated location. The company claims that these treat‐
ments provide both root decontamination and maximal release of embedded proteins. Once all
the parts were installed and the machine’s cover was closed, the general switch button was
used to turn on the device. After 25 min, the demineralized dentin graft was ready to be intro‐
duced into the patient’s mouth (TT TOOTH TRANSFORMER SRL, Milan, Italy), along with
Xenograft (Bio-Oss Geistlich Pharma AG) in a 50% proportion. An absorbable collagen mem‐
brane (Osseoguard–Zimmer) was used to cover the grafts and extend approximately 2–3 mm
beyond the borders of the bone defect. Amoxicillin was administered in doses of 1000 mg ev‐
ery 12 h, or 2000 mg BID for 10 to 14 days. One week after the procedure, the sutures were
removed. After four months of healing, biopsies were performed during implant placement us‐
ing a trephine cylindrical drill with graduated depth markings (ranging from 5 to 18 mm) and
abundant sterile saline irrigation. After another 4 months, during the implant healing period or
healing screw insertion, another biopsy was performed using a smaller diameter trephine
cylindrical drill with graduated depth markings (ranging from 5 to 18 mm) under copious ster‐
ile saline irrigation.
2.5. Collection and Statistical Analysis of Data
Records of patients, including histological and morphometric data, were collected and stored in
separate files, in compliance with privacy legislation. To establish accurate reference values for
comparison with other studies and between the two groups, the average values of the morpho‐
metric data were calculated.
2.6. Histological Technique
Histomorphometric analysis was conducted on both decalcified and non-decalcified bone sam‐
ples. The bone quantification procedure was consistent for both types of biopsies, ensuring
that the quantification of new bone did not significantly impact data collection [51,52].
Decalcified:
The samples were sliced, embedded in paraffin, and subjected to decalcification. The samples
were preserved in 10% neutral buffered formalin for 7 days, consisting of a solution of 37%
formaldehyde, 10 mL of NaCl, 0.8 g of potassium phosphate monobasic, 0.65 g of potassium
phosphate dibasic, and 90 mL of distilled water. Disodium EDTA pH 7 was used for decalcifica‐
tion until complete decalcification was achieved, determined by physical examination.
Subsequently, the samples were dehydrated in ethanol with increasing concentrations from
70% to 100%, cleaned with xylene, and embedded in paraffin using Carlo Erba reagents.
Paraffin slides were cut using the Lecia RM2245 (Leica Biosystems, Milan, Italy) rotatory micro‐
tome and mounted on superfrost microscope glass slides with Biomount HM (Bio-Optica
Milano Spa, Milan, Italy). Histology images obtained from the Olympus transmitted light micro‐
scope were converted to digital photographs using a digital camera and analyzed using the im‐
age analysis program IAS 2000 (QEA). The following histomorphometric measurements were
calculated for each sample:
BV%: Percentage of mineralized tissue excluding medullary tissues.

Graft%: Percentage of the volume occupied by the remaining graft or dentin.
VB%: Percentage of vital bone excluding medullary tissues. The sum of TT% and VB%
represented the BV%. Each subsection was measured using the ImageJ 1.52q program.
Non-decalcified:
Each sample underwent dehydration using a series of alcohol solutions with increasing con‐
centrations until reaching pure alcohol, followed by infiltration with methacrylic resin. After the
resin was light-cured, non-decalcified sections were obtained using a disk abrasion system
(LS2-Remet, Bologna, Italy) and a diamond disk cutting system (Micromet-Remet, Bologna,
Italy). The region of interest in the biopsy was exposed by removing the resin component cov‐
ering the sample through resin abrading. The exposed surface was then attached to a show‐
case using cyanoacrylate adhesives. Subsequently, the sample was cut with a high-speed dia‐
mond blade under cooling conditions to obtain a thickness of approximately 200 μm, which
was further thinned by abrasion to about 40–50 μm. The slide was polished with polishing pa‐
pers and stained with basic fuchsin and blue toluidine for final observation under light and po‐
larized light microscopy.
For histomorphometric measurements, the histological images obtained from the transmitted
light microscope were digitized through a digital camera and analyzed by means of image
analysis software IAS 2000.
For each sample, the following were calculated using histomorphometric analysis:
BV% = Percentage of residual bone volume, excluding medullary tissues;

Graft% = Percentage of the remaining graft, without bone and marrow;
VB% = Percentage of vital bone, excluding the bone marrow and the residual graft.
3. Results
Both hard and soft tissues remained steady throughout the healing process. There were no dif‐
ficulties with the soft tissue grafting treatments’ healing. After a healing period of 4 months,
seven biopsies (Figure 2 and Figure 3) were performed during the implant insertion proce‐
dure; after the healing period (8 months after the socket preservation procedure), seven biop‐
sies were performed (Figure 4 and Figure 5).
Figure 2
First histology after 4 months healing.
Figure 3
Histology from 4 months healing In this histological image, the remaining xenograft material granules can be
observed—marked with X. The residual dentin granules are marked with D. The bone tissue is highlighted
with B. It is evident, both visually and as supported by histomorphometry, that the xenograft material gran‐
ules were less resorbed compared to the dentin granules.
Figure 4
Second histology after 8 months of healing.
Figure 5
Histology after 8 months from the same patient. In this histological image, the remaining xenograft material
granules can be observed—marked with X. The residual dentin granules are marked with D. The bone tissue
is highlighted with B. It is evident, both visually and as supported by histomorphometry, that the xenograft
material granules were less resorbed compared to the dentin granules.
The results of the histomorphometric analysis of the graft biopsies are presented in Table 1.
The syringe test indicated that approximately 60% of the space was occupied by the graft,
while the remaining 40% represented the space between the granules (Table 2).
Table 1
The mean histomorphometry of the samples shows the percentage of graft loss relative to the initial quantity
of graft inserted in the socket preservations. This table presents the changes in the percentages of dentin, Bio-
Oss, and bone over time, as determined by histomorphometry. Additionally, a separate table illustrates the
percentage resorption rate of the two materials for comparison.
Residual Graft Dentin Loss Residual Graft Bio-Oss Loss

BV% NB%
Dentin % Percentage Bio-Oss % Percentage
4 29.03±
65.66% 8.68 ± 3.36% 71% 27.95 ± 5.23% 6.74%
Months 6.57%
8 34.12 ±
59% 2.79 ± 1.48 90.71% 22.09 ± 13.81 26.42%
Months 5.05
Table 2
Percentage of space occupied by granules and water.
Granules Water
Percentage of space 100% 60% 40%
Initially, the graft composition was 30% dentin graft and 30% Bio-Oss, accounting for 60% of
the total space occupied by the combined graft. The remaining 40% represented the space be‐
tween the individual graft granules.
Over time, the graft percentages changed significantly. After 4 months, the volume percentage
of the dentin graft decreased by 71%, while the Bio-Oss graft only decreased by 6.74%. After 8
months, the dentin graft volume percentage decreased by 90.71%, while the Bio-Oss graft vol‐
ume percentage decreased by 26.42%. Figure 6 highlights an interesting inverse relationship
between the dentin curve and the new bone curve. It can be observed that the BV% (Bone
Volume %) decreased over time, while the NB% (New Bone %) increased. This can be attrib‐
uted to the reabsorption of the graft material, and demonstrates the relationship between the
remaining graft quantity and the rate of reabsorption.
Figure 6
This graph illustrates the different rates of resorption of the two materials, observed through histomorphome‐
try at 4 months and 8 months. Initially, at time zero, both the dentin and Bio-Oss grafting materials occupied
60% of the space, with no newly formed tissue present.
At four months, the dentin (blue line) showed partial resorption, measuring approximately 8%.
In contrast, the Bio-Oss material (red line) exhibited less pronounced resorption, with approxi‐
mately 28% remaining. The gray line representing the bone tissue showed an increase of 29%.
By eight months, the trend in dentin resorption persisted, and the blue line dropped to around
2%—indicating that 90.71% of the dentin had been resorbed. The resorption of Bio-Oss, repre‐
sented by the red line, remained at approximately 22.9%—indicating that only 26% of the Bio-
Oss material had been resorbed. Meanwhile, the bone tissue, benefiting from the resorption of
the two biomaterials, had grown within the spaces and accounted for 34% of resorption (gray
line).
4. Discussion
The main objective of this study was to investigate cases where a minimal tooth structure ex‐
isted for regeneration, requiring the addition of grafting material. The aim was to assess the ef‐
fectiveness of this approach and determine if it demonstrated any desirable qualities.
Numerous clinical investigations have examined the healing mechanisms of post-extraction

sites following bone grafting procedures, focusing on various graft materials [18,53,54,55].
Recent systematic reviews and meta-analyses have shown that xenogeneic materials generally
perform well. Surgeries utilizing allografts have the lowest percentages of remaining graft ma‐
terial (12.4–21.11%), while those using xenografts and alloplasts yield better results after 7
months (37.14% and 37.23%) [18].
From a therapeutic perspective, it has been suggested that this family of grafts may reduce
tridimensional shrinkage of the bony crest if sealed with a collagen membrane. However, from
a histological perspective, these materials could potentially result in incomplete resorption due
to their composition. The bone regeneration scaffold should provide structural support for
bone development, possess mechanical qualities similar to the host bone, be biocompatible,
and degrade at a rate compatible with bone remodeling [18].
The use of tooth grafts for socket preservation has been described in different studies. Kim et
al. suggest utilizing autogenous fresh demineralized tooth grafts created chairside immediately
after extraction. Radiographs reveal good bony healing, while histologic sections have demon‐
strated appropriate new bone development and resorption patterns [56]. Minetti et al. em‐
ployed demineralized dentin matrix derived from vital or endodontically treated teeth in com‐
bination with a collagen membrane for post-extraction site preservation [36].
This study builds upon considerations made by Lindhe and Norton, who observed that the
placement of Bio-Oss or non-resorbable graft materials in fresh extraction sockets delayed
healing, as the particles were not resorbed, but instead were surrounded by new bone
[10,57,58,59].
A total of 25 patients undergoing single-tooth extraction and implant placement were included
in the study. They were divided into two groups: the test group, in which the socket was filled
with Bio-Oss collagen (Geistlich Pharma, Wolhusen, Switzerland) and covered with a collagen
membrane (Mucograph, Geistlich Pharma), and the control group, in which the socket was
filled with a blood clot and covered with a collagen membrane (Mucograph, Geistlich Pharma).
After six months of healing, non-inflamed tissues were observed in both test and control sites.
However, in the control sites, cortical bone was present, whereas in the Bio-Oss collagen-
grafted sites, distinct cortical bone was lacking; histological analysis revealed compromised
central and apical regions, with the biomaterial surrounded by connective tissue [45].
The average amount of new bone indicated in the study was 26.9% and 25.6% for the
xenograft material (Bio-Oss) [13]; this can be attributed to the phagocytic abilities of osteo‐
clasts, the bone-resorbing cells, and the low pH they create in their surroundings, leading to
the dissolution of hydroxyapatite (HAP) ceramics upon contact with mineral cells [60].
The challenge arises from the fact that most sintered HAP ceramics—even the porous ones—
have large crystals that are difficult to remodel [61].
Some authors suggest that the presence of non-resorbable graft materials makes it difficult for
new bone to grow, as the space is occupied by the graft [10].
In contrast, dentin—after appropriate treatment—undergoes almost complete resorption. In a

recent histological publication, the effectiveness of dentin as a graft in alveolar socket preserva‐
tion (ASP) procedures was evaluated through the first prospective histomorphometric evalua‐
tion. A total of 101 histologies from 96 subjects (50 females and 46 males) with a mean age of
56.3 ± 14.7 years were analyzed after guided bone regeneration (GBR) procedures using the
ToothTransformer treatment. After an average healing time of 5.2 ± 1.9 months, the residual
graft amounted to 7.7 ± 12.2% in the maxilla and 7.0 ± 11.1% in the mandible [62].
Therefore, in cases where there is a reduced amount of dentin—insufficient for proper socket
preservation—the addition of a reabsorbable biomaterial to Bio-Oss or a non-resorbable graft
material may have advantages. This is due to the resorption of dentin, creating space for new
bone to form.
Table 1 illustrates that the Bone Volume % (BV%) and New Bone % (NB%) have an inverse re‐
lationship over time. This is attributed to the resorption of the graft material, and the relation‐
ship between the remaining graft quantity and the rate of reabsorption can be understood.
In Table 1, it can be observed that the BV% remained at around 60% (65% at 4 months and
59% at 8 months), indicating that the volume was maintained over time—but the distribution
of the volume changed. Initially, the graft was composed of 30% dentin graft and 30% Bio-Oss
—occupying 60% of the space, with the remaining 40% representing the space between indi‐
vidual graft granules. Over time, the graft percentages exhibited significant differences: the
dentin graft volume decreased by 71%, while the Bio-Oss graft volume only decreased by
6.74%. After 8 months, the dentin graft volume % decreased by 90.71%, and the Bio-Oss graft
volume % decreased by 26.42%. Table 2 highlights the interesting inverse similarity between
the dentin curve and the new bone curve.
The histological results of the treated dentin with TT (ToothTransformer) were comparable to
a recent publication that analyzed 101 histologies after guided bone regeneration (GBR) proce‐
dures using TT [62].
5. Conclusions
The present study revealed different rates of reabsorption between two distinct graft materials
during the healing process. It is interesting to note that the space created by dentin reabsorp‐
tion contributes to an increased quantity of new bone compared to the insertion of xenograft
material alone.
This study aimed to address the issue of the limited availability of natural tooth material for
grafting and the need to supplement it with alternative materials from different sources. This
question has remained unanswered in the scientific community until now. Despite the limita‐
tions in sample size, we endeavored to provide an answer to this inquiry. Undoubtedly, the use
of a resorbable grafting material in combination with a partially resorbable material ensures
superior outcomes compared to the use of only a partially resorbable material; this is because
the space occupied by the graft granules becomes readily available for new bone formation,
while the structure is maintained by the non-resorbed granules.
Given the limitations in the number of samples and the constraints of the histomorphometric
analysis (such as the dimensions and location of the biopsy), we recommend conducting fur‐
ther studies—particularly randomized controlled clinical trials with larger sample sizes—to
confirm the results already obtained in a significant number of pilot studies.
Abbreviations
BMPs Bone Morphogenetic Proteins
ECM Extracellular Matrix
TT Tooth Transformer
BV Bone Volume
NB New Bone
Funding Statement
This research received no external funding.
Author Contributions
Conceptualization, E.M., A.P. (Andrea Palermo) and P.S.; methodology, A.D.I., A.M.I. and F.I.; soft‐
ware, P.S., and B.R.; validation, A.P. (Andrea Palermo) and G.D.; formal analysis, A.P. (Assunta
Patano), and G.M.; investigation, E.M., F.C.T. and B.R.; resources, A.D.I.; data curation, E.M. and
P.S.; writing—original draft preparation, E.M. and A.P. (Andrea Palermo); writing—review and
editing, A.P. (Assunta Patano) and G.M.; visualization, A.M.I.; supervision, F.I. and G.D.; project
administration, F.I., G.D. and A.M.I. All authors have read and agreed to the published version of
the manuscript.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki, and approved by the
local Ethics Committee of University of Chieti (protocol N. 1869 12 December 2018).
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement
Not applicable.
Conflicts of Interest
The authors declare no conflict of interest.
Footnotes
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Socket Preservation Using Dentin Mixed With Xenograft Materials - A Pilot Study - PMC

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3/7/24, 6:34 PM Socket Preservation Using Dentin Mixed with Xenograft Materials: A Pilot Study - PMC

Materials (Basel). 2023 Jul; 16(14): 4945. PMCID: PMC10382043

Nikolaos Silikas, Academic Editor

2. Materials and Methods

2.1. Study Design and Patient Selection

2.2. Inclusion Criteria

2.3. Exclusion Criteria

2.4. Surgical Procedures and Follow-Up

2.5. Collection and Statistical Analysis of Data

2.6. Histological Technique

BV%: Percentage of mineralized tissue excluding medullary tissues.

BV% = Percentage of residual bone volume, excluding medullary tissues;

First histology after 4 months healing.

Second histology after 8 months of healing.

Residual Graft Dentin Loss Residual Graft Bio-Oss Loss

Percentage of space occupied by granules and water.

Percentage of space 100% 60% 40%

Numerous clinical investigations have examined the healing mechanisms of post-extraction

In contrast, dentin—after appropriate treatment—undergoes almost complete resorption. In a

BMPs Bone Morphogenetic Proteins

ECM Extracellular Matrix

This research received no external funding.

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

The authors declare no conflict of interest.

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